See If You Qualify | Vias Family Building

Let’s start with you.

We’ll start with a few basic details so we can contact you and confirm that you meet the initial age and location requirements.

First name *

Last name *

Email *

Mobile phone *

Date of birth *

State of residence *

Surrogates must have carried and delivered at least one child. We review details later in the full application.

Number of pregnancies *

Number of deliveries *

Number of C-sections *

Year of most recent delivery

Are you currently raising at least one child you gave birth to? *

YesNo

Did any pregnancy involve a serious complication or very early delivery? *

YesNo

A “yes” answer does not always mean automatic disqualification.

Height

Weight

Do you currently use cigarettes, vaping products, nicotine, marijuana, or recreational drugs? *

YesNo

Are you currently pregnant or breastfeeding? *

YesNo

Do you have reliable transportation and a realistic childcare/support plan? *

YesNo

Have you or an adult in your household been convicted of a serious criminal offense? *

YesNo

Tell us what brought you here and the best way to reach you.

What interests you about becoming a surrogate?

Preferred contact method *

Best time to contact you

How did you hear about Vias?

Submitting this form does not guarantee eligibility or create an agency relationship. Full screening and clinic approval are required.